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Program Integrity: How Much Money Can Combating Health Care Fraud and Abuse Save?

Monday, March 05, 2012

Headlines regularly call attention to pockets of fraudulent activity in the health care area--scams that amount to millions and potentially billions of dollars. The stories typically focus on catching the "crooks" but not so much on efforts to prevent fraud, waste and abuse in health care programs. Both types of efforts are important. With continued concerns about rising health care costs and the current focus on deficit reduction, how much money can be saved and put to better use by reducing waste, abuse and outright fraud?

Initiatives to stop fraud and abuse in health care have been evolving. The Deficit Reduction Act of 2005 created the Medicaid Integrity Program, the first comprehensive federal strategy to prevent and reduce provider fraud, waste, and abuse in Medicaid. The Patient Protection and Affordable Care Act provided new tools to enhance and coordinate CMS' efforts to prevent fraud in Medicare, Medicaid and the Children’s Health Insurance Program. More recent proposals seek to crack down even further on fraud and abuse.

What new challenges arise as states move from fee-for-service Medicaid to managed care initiatives? Is lack of coordination between state Medicaid agencies and their Medicaid Fraud Control Units hampering program integrity efforts? Have some states conquered this problem? Are Medicaid agencies adequately staffed to deal with fraud and abuse? What are some private sector efforts in fraud control? How are Medicare beneficiaries and providers collaborating with HHS? How can advanced information systems enhance fraud control efforts in public and private programs?

To address these questions and more, the Alliance for Health Reform and the Centene Corporation sponsored a March 5 briefing. The focus was not so much on the criminal aspect of the problem, but rather on how to coordinate the efforts of Medicaid, Medicare, the private sector and others to prevent and combat the waste, fraud and abuse. Panelists were: Peter Budetti, director of the Center for Program Integrity at CMS; Jim Frogue, founder of the government relations firm FrogueClark; Doug Porter, Washington State Medicaid director; and Bill Hazel, secretary of the Virginia Department of Health and Human Resources. Glen Schuster, chief technology officer of the Centene Corporation and Ed Howard of the Alliance co-moderated.

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